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Jia XH, Kong S, Gao XX, Cong BC, Zheng CN. Intestinal malrotation complicated with gastric cancer: A case report. World J Clin Cases 2024; 12:210-216. [PMID: 38292641 PMCID: PMC10824180 DOI: 10.12998/wjcc.v12.i1.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/22/2023] [Accepted: 12/15/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Intestinal malrotation is a congenital defect of embryonic development caused by various teratogenic factors. In this condition, the intestinal tube, along with the superior mesenteric artery serving as the axis for the counterclockwise movement, is incomplete or abnormally rotated due to incomplete attachment of the mesentery and abnormal intestinal tube position. Such a case is usually asymptomatic and thus difficult to detect. Therefore, similar variant malformations are only found during an operation required for other abdominal diseases. CASE SUMMARY An elderly male patient was admitted to the hospital due to gastric cancer. An abdominal computed tomography (CT) scan with contrast revealed that the ascending and descending colon were parallel on the right side of the abdominal cavity, while the sigmoid colon extended into the right iliac fossa, allowing the diagnosis of congenital midgut malrotation. Following thorough preoperative preparation, the patient underwent laparoscopic radical gastrectomy to treat his gastric cancer. Intraoperatively, an exploration of the abdominal cavity uncovered the absence of the transverse colon. The distal colon at the hepatic flexure, along with the ascending colon, extended into the right iliac fossa, where it continued as the sigmoid colon. As planned, the laparoscopic radical gastrectomy was performed, and the patient was discharged from the hospital 7 d after the surgery. CONCLUSION Asymptomatic intestinal malrotation is best detected by CT, requiring no treatment but possibly interfering with the treatment of other diseases.
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Affiliation(s)
- Xiang-Hao Jia
- School of Clinical Medicine, Weifang Medical University, Weifang 261053, Shandong Province, China
| | - Shuai Kong
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Xin-Xin Gao
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Bi-Cong Cong
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Chun-Ning Zheng
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
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Wang XL, Jin GX, Xu JF, Chen ZR, Wu LM, Jiang ZL. Right paraduodenal hernia, classification, and selection of surgical methods: a case report and review of the literature. J Med Case Rep 2023; 17:536. [PMID: 38158564 PMCID: PMC10757357 DOI: 10.1186/s13256-023-04286-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Considering that right paraduodenal hernia is a rare internal hernia with abnormal anatomy and is often encountered during an emergency, surgeons may lack knowledge about it and choose incorrect treatment. Thus, this case report is a helpful complement to the few previously reported cases of right paraduodenal hernia. Additionally, we reviewed all the reported right paraduodenal hernia cases and proposed appropriate surgical strategies according to different anatomical features. CASE PRESENTATION The case involved a 33-year-old Chinese male patient who was admitted to the hospital due to abdominal pain. The patient was initially diagnosed with small bowel obstruction, and conservative treatment failed. An emergency operation was arranged, during which a diagnosis of right paraduodenal hernia was made instead. After surgery, the patient recovered well without abdominal pain for 2 years. CONCLUSION Although right paraduodenal hernia accounts only for a small proportion of paraduodenal hernia, its anatomical characteristics can vary considerably. We divided right paraduodenal hernia into three types, with each type requiring a different surgical strategy.
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Affiliation(s)
- Xiao-Long Wang
- Department of General Surgery, Taixing People's Hospital, No. 1, Changzheng Road, Taixing, Jiangsu, China
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Gui-Xiu Jin
- Department of Gynecology and Obstetrics, Taixing People's Hospital, Taixing, Jiangsu, China
| | - Jian-Feng Xu
- Department of General Surgery, Taixing People's Hospital, No. 1, Changzheng Road, Taixing, Jiangsu, China
| | - Zhi-Rong Chen
- Department of General Surgery, Taixing People's Hospital, No. 1, Changzheng Road, Taixing, Jiangsu, China
| | - Li-Meng Wu
- Department of Radiology, Taixing People's Hospital, Taixing, Jiangsu, China
| | - Zhi-Long Jiang
- Department of General Surgery, Taixing People's Hospital, No. 1, Changzheng Road, Taixing, Jiangsu, China.
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Eltayb AB, Hegazi A, Elhag O, Abdelgadir A. Midgut volvulus due to congenital malrotation in an adult: a case report. J Med Case Rep 2023; 17:378. [PMID: 37620962 PMCID: PMC10463942 DOI: 10.1186/s13256-023-04096-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Intestinal Malrotation is congenital that complicates 1 in every 200 births. It results from abnormal fixation and rotation of the gut tube during fetal development. It is usually asymptomatic and most cases are diagnosed during childhood and the condition is seldom seen in adults. Also, it can present as an incidental finding in imaging or patients undergoing laparotomy for other reasons. Midgut Volvulus can lead to small obstruction it warrants surgical intervention. CASE PRESENTATION Our case is a 20 years old black African male from Khartoum (Sudan) who presented to the emergency department with features of intestinal obstruction he was resuscitated and underwent a CT scan of the abdomen that showed malrotation of the intestine with volvulus for which he underwent a Ladd procedure. CONCLUSION Small bowel obstruction due to volvulus complicating malrotation is a rare presentation in adulthood and the Ladd procedure can be utilized to manage such case.
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Affiliation(s)
| | - Albra Hegazi
- Sudan Medical Specialization broad, Al Khurtum, Sudan
| | - Osaman Elhag
- Sudan Medical Specialization broad, Al Khurtum, Sudan
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Unique coexistence of chronic midgut malrotation, mesenteric cyst, and pancreas divisum in a Crohn's disease patient: MR-enterography assessment. Radiol Case Rep 2022; 17:4280-4285. [PMID: 36124320 PMCID: PMC9482081 DOI: 10.1016/j.radcr.2022.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/10/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022] Open
Abstract
Chronic midgut malrotation is a rare condition found in the adult age that predisposes to severe complications. It derives from an incomplete rotation of the mesentery around the superior mesenteric artery during embryogenic development. This results in intestinal loops displacement and mesenteric malfixation. Nevertheless, other congenital abnormalities can be also associated, such as mesenteric cysts and biliopancreatic malformations. Imaging modalities employed in the evaluation of chronic midgut malrotation include contrast radiography, which permits to visualize the localization of the intestinal loops, and ultrasound, that can detect a twist of superior mesenteric vessels. Computed tomography is however considered the modality of choice, owing to its wide field of view and the rapid scan times. The role of magnetic resonance imaging in this field has been barely explored. In particular, magnetic resonance enterography has a consolidated role in the assessment of intestinal loops and allows detecting extra-intestinal findings as well. Moreover, the lack of radiation exposure makes this technique suitable for nonemergency cases, especially in young patients. This is the first description of simultaneous chronic midgut malrotation, mesenteric cyst and pancreas divisum discovered in a Crohn's disease patient. The performance of magnetic resonance enterography allowed to properly interpret this multifaceted clinical picture.
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Lodhia J, Salewi AK, Sway H, Sadiq A, Msuya D. Late presentation of midgut malrotation in a young adult. J Surg Case Rep 2022; 2022:rjac515. [DOI: 10.1093/jscr/rjac515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/21/2022] [Indexed: 11/21/2022] Open
Abstract
Abstract
Midgut malrotation is a congenital anomaly due to partial or complete failure of rotation of the midgut in fetal life. Majority of the cases present in the neonatal period and 90% within the first year. Adult presentation is rare and the true incidence is unknown as some cases pass undiagnosed. Whirlpool sign is pathognomic for midgut malrotation and management involves surgery.
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Affiliation(s)
- Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
- Faculty of Medicine, Kilimanjaro Christian Medical University College , Moshi , Tanzania
| | | | - Happiness Sway
- Faculty of Medicine, Kilimanjaro Christian Medical University College , Moshi , Tanzania
- Department of Anesthesia and Critical Care, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Adnan Sadiq
- Faculty of Medicine, Kilimanjaro Christian Medical University College , Moshi , Tanzania
- Department of Radiology, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - David Msuya
- Department of General Surgery, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
- Faculty of Medicine, Kilimanjaro Christian Medical University College , Moshi , Tanzania
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Nguyen MTT, Ali A, Bodkin RP. Small Bowel Volvulus as Delayed Presentation of Undiagnosed Crohn's Disease: A Case Report. Clin Pract Cases Emerg Med 2021; 5:455-458. [PMID: 34813443 PMCID: PMC8610472 DOI: 10.5811/cpcem.2021.8.53524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/02/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Emergency department (ED) visits related to flare-ups of inflammatory bowel disease (IBD) are becoming more prevalent. There are many potentially dangerous complications and sequelae of uncontrolled IBD. Case Report We report a case of a middle-aged woman who presented with a few hours of severe abdominal pain, nausea, and vomiting. Given her hemodynamic instability, she was sent urgently for computed tomography, which showed an incomplete small bowel malrotation, mesenteric volvulus, and high-grade small bowel obstruction with evolving ischemia. The patient underwent exploratory laparotomy to resect most of her small intestines. Biopsies later revealed active Crohn’s disease. Conclusion Patients with flare-ups of IBD are common in the ED, but very few present with a midgut volvulus later in life. Our case is unique and adds to the literature due to the dramatic consequences of undiagnosed Crohn’s disease in a patient with intermittent symptoms and extensive workup spanning over two decades.
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Affiliation(s)
- Minh Thu T Nguyen
- University of Rochester Medical Center, Department of Internal Medicine, Rochester, New York
| | - Amir Ali
- University of Rochester Medical Center, Department of Emergency Medicine, Rochester, New York
| | - Ryan P Bodkin
- University of Rochester Medical Center, Department of Emergency Medicine, Rochester, New York
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7
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Abu-Elmagd K, Mazariegos G, Armanyous S, Parekh N, ElSherif A, Khanna A, Kosmach-Park B, D'Amico G, Fujiki M, Osman M, Scalish M, Pruchnicki A, Newhouse E, Abdelshafy AA, Remer E, Costa G, Walsh RM. Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure. Ann Surg 2021; 274:581-596. [PMID: 34506313 PMCID: PMC8428856 DOI: 10.1097/sla.0000000000005072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established. METHODS Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients. RESULTS The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001). CONCLUSIONS Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.
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Affiliation(s)
| | - George Mazariegos
- University of Pittsburgh Medical Center and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Neha Parekh
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Ajai Khanna
- University of Pittsburgh Medical Center and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Beverly Kosmach-Park
- University of Pittsburgh Medical Center and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Erick Remer
- Cleveland Clinic Foundation, Cleveland, Ohio
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Xiong Z, Shen Y, Morelli JN, Li Z, Hu X, Hu D. CT facilitates improved diagnosis of adult intestinal malrotation: a 7-year retrospective study based on 332 cases. Insights Imaging 2021; 12:58. [PMID: 33929625 PMCID: PMC8087751 DOI: 10.1186/s13244-021-00999-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/21/2021] [Indexed: 12/17/2022] Open
Abstract
Objective To classify adult intestinal malrotation by CT. Methods This retrospective study enrolled adults diagnosed with intestinal malrotation who underwent abdominal CT at our institution between June 1, 2013, and August 30, 2020. All patients’ clinical information was recorded. Patients were divided into groups undergoing surgical and conservative management. The duodenum (nonrotation, partial rotation, and malrotation), jejunum, cecum, and the superior mesenteric artery/superior mesenteric vein relationship were reviewed on the CT images of each patient, and classification criteria developed based on the first three items. For each patient, each item was assessed separately by three radiologists. Consensus was required from at least two of them. Results A total of 332 eligible patients (218 men and 114 women; mean age 51.0 ± 15.3 years) were ultimately included and classified into ten types of malrotation. Duodenal partial rotation was present in most (73.2%, 243/332) with only 25% (83/332) demonstrating nonrotation. The jejunum was located in the right abdomen in 98.2% (326/332) of cases, and an ectopic cecum was found in only 12% (40/332, 29 cases with a left cecum, 7 pelvic, and 4 at midline). Asymptomatic patients comprised 56.6% (188/332) of cases, much higher than that in previous studies (17%, n = 82, p < .001), comprised mainly of patients with duodenal partial rotation (80.3%, 151/188). In 91 patients with detailed clinical data available (12 managed surgically and 79 conservatively), a significant difference in malrotation CT categorization was identified (p = .016). Conclusions CT enables greater detection of asymptomatic intestinal malrotation, enabling classification into multiple potentially clinically relevant subtypes. Supplementary Information The online version contains supplementary material available at 10.1186/s13244-021-00999-3.
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Affiliation(s)
- Ziman Xiong
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China.
| | - John N Morelli
- Department of Radiology, St. John's Medical Center, Tulsa, OK, USA
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
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9
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Neville JJ, Gallagher J, Mitra A, Sheth H. Adult Presentations of Congenital Midgut Malrotation: A Systematic Review. World J Surg 2021; 44:1771-1778. [PMID: 32030442 DOI: 10.1007/s00268-020-05403-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation. METHODS A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed. RESULTS Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9 years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd's procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively). CONCLUSION Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.
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Affiliation(s)
- Jonathan J Neville
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK. .,Imperial College Healthcare NHS Trust, Paddington, London, W2 1NY, UK.
| | - Jack Gallagher
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK.,Imperial College Healthcare NHS Trust, Paddington, London, W2 1NY, UK
| | - Anuja Mitra
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK.,Imperial College Healthcare NHS Trust, Paddington, London, W2 1NY, UK
| | - Hemant Sheth
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK
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Pasculli A, Gurrado A, Vittore F, De Luca GM, Sammarco A, Testini M. Robotic-assisted treatment of intestinal malrotation in an adult man - a video vignette. Colorectal Dis 2020; 22:2335-2336. [PMID: 32668098 DOI: 10.1111/codi.15267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/29/2020] [Indexed: 02/08/2023]
Affiliation(s)
- A Pasculli
- Department of Biomedical Science and Human Oncology, Academic Unit of General Surgery 'V. Bonomo', University of Bari 'Aldo Moro', Bari, Italy
| | - A Gurrado
- Department of Biomedical Science and Human Oncology, Academic Unit of General Surgery 'V. Bonomo', University of Bari 'Aldo Moro', Bari, Italy
| | - F Vittore
- Department of Biomedical Science and Human Oncology, Academic Unit of General Surgery 'V. Bonomo', University of Bari 'Aldo Moro', Bari, Italy
| | - G M De Luca
- Department of Biomedical Science and Human Oncology, Academic Unit of General Surgery 'V. Bonomo', University of Bari 'Aldo Moro', Bari, Italy
| | - A Sammarco
- Department of Biomedical Science and Human Oncology, Academic Unit of General Surgery 'V. Bonomo', University of Bari 'Aldo Moro', Bari, Italy
| | - M Testini
- Department of Biomedical Science and Human Oncology, Academic Unit of General Surgery 'V. Bonomo', University of Bari 'Aldo Moro', Bari, Italy
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Brungardt JG, Liebscher SC, Schropp KP. Malrotation Correction in the Adult Population. World J Surg 2020; 45:141-147. [PMID: 32975648 DOI: 10.1007/s00268-020-05790-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Malrotation is a congenital anomaly most often affecting the pediatric population. The Ladd procedure is the standard treatment for this pathology. Well-studied in the pediatric population, large studies of the demographics and outcomes of patients who reach adulthood are lacking. METHODS An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2015-2018) was performed, capturing patients with a post-operative diagnosis of malrotation and who underwent surgical correction with or without appendectomy, excluding those who underwent other major procedures such as colectomy. Baseline demographics and outcomes were compared. The primary outcome was mortality. Secondary outcomes such as length of stay and discharge destination were included. RESULTS Two hundred twenty patients undergoing surgical correction of malrotation were captured, all of which were performed by a general surgeon under general anesthesia. One hundered and nine (49.55%) of these patients also underwent an appendectomy. Most of these patients were female (68.18%). Comorbidities and perioperative variables were clinically similar. Operative time was similar between the two groups (112 ± 86 vs. 98 ± 49 min, p = 0.1385). Thirty-day mortality (1.36%), length of stay (4.79 ± 6.21 days), readmission rate (13.64%), wound infection (2.27%) and discharge destination (95.00% to home) were statistically similar between groups. CONCLUSIONS The data describes demographics and outcomes in adults undergoing Ladd procedures with and without appendectomy. Immediate outcomes may be equivalent regardless of incidental appendectomy. Further work is necessary to describe the population of adults with malrotation reaching adulthood.
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Affiliation(s)
- Joseph G Brungardt
- Department of Surgery, The University of Kansas, 4000 Cambridge, M/S 2005, Kansas City, KS, 66160, USA.
| | - Sean C Liebscher
- Department of Surgery, The University of Kansas, 4000 Cambridge, M/S 2005, Kansas City, KS, 66160, USA
| | - Kurt P Schropp
- Department of Surgery, The University of Kansas, 4000 Cambridge, M/S 2005, Kansas City, KS, 66160, USA
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13
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Zhao XY, Wang X, Li CQ, Zhang Q, He AQ, Liu G. Intestinal obstruction in pregnancy with reverse rotation of the midgut: A case report. World J Clin Cases 2020; 8:3553-3559. [PMID: 32913863 PMCID: PMC7457094 DOI: 10.12998/wjcc.v8.i16.3553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/30/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reverse rotation of the midgut is a rare type of intestinal malrotation. Volvulus of the right colon or entire midgut, stenosis of the transverse colon and obstruction of the duodenojejunal junction are common complications of reverse rotation. In this study, we report the first case of intestinal obstruction associated with reverse rotation in pregnancy.
CASE SUMMARY A 31-year-old woman at 36+2 wk gestation presented to the emergency department with progressive abdominal cramping, nausea and bilious vomiting. Abdominal ultrasound scanning showed dilatation of the bowel. Computed tomography scanning revealed features of reverse rotation of the midgut with intestinal volvulus. After consultation with the obstetrician, the pregnancy was terminated and exploratory abdominal surgery was performed. Intra-operatively, it was found that the mesentery of the colon and small intestine was insufficiently attached. The right colon and the small intestinal mesentery was twisted, and intestinal necrosis was observed. The duodenum and duodenojejunal junction were curved in front of the transverse colon, and the transverse colon passed through the tunnel behind the mesenteric root. Intestinal reverse rotation with volvulus was confirmed. The necrotic intestine was resected and small intestine mesenteric reconstruction was performed. The patient recovered after surgery. After leaving the hospital, the patient and her daughter remained well during an 8-month follow-up period.
CONCLUSION We report the diagnosis, treatment and etiology of a pregnant patient with intestinal obstruction due to reverse rotation of the midgut. For similar cases, appropriate diagnosis and treatment should be carried out according to the condition of the fetus and pregnant woman.
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Affiliation(s)
- Xin-Yu Zhao
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xin Wang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Chun-Qiang Li
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qi Zhang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - An-Qi He
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
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Perez Galaz F, Moedano Rico K, Pérez Tristán FA, Acuña Macouzet A, Jafif Cojab M. Midgut volvulus caused by intestinal malrotation; A rare cause of acute abdomen in adults. Case report. Int J Surg Case Rep 2020; 73:355-359. [PMID: 32745727 PMCID: PMC7398895 DOI: 10.1016/j.ijscr.2020.07.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 12/18/2022] Open
Abstract
Midgut volvulus caused by malrotation. Midgut volvulus as a rare cause of acute abdomen in adulthood. Intestinal malrotation presentation in the adulthood.
Introduction Acute abdomen due to midgut volvulus with intestinal malrotation is rare event with only only few cases in the literature Butterworth et al. (2018). Intestinal malrotation presented in the adulthood is reported in 0.2−0.5 %, of cases; with only 15 % f them presenting as midgut volvulus Butterworth et al. (2018). Intestinal malrotation is casued by an alteration in embryonic development between 10–12 weeks of gestation. The main alteration is anomalous position of the bowel with the small intestine residing on the right side of the abdomen, while the colon and cecum remain on the left side due to malposition of the Treitz ligament. Additionally, the ascending colon remains attached to the abdominal wall by fibrous peritoneal bands known as Ladd bands, this being a cause of midgut volvulus and intestinal obstruction. Presentation of Case We present a 25-year-old male with failure to thrive who arrives at the ED with clinical signs and symptoms of intestinal occlusion and acute abdomen, initial resuscitation is made in ED and is transferred to OR, an exploratory laparoscopy evidencing intestinal malrotation with cecal volvulus and a Ladd procedure is made openly without PO complications. Discussion The gold standard for diagnosis of intestinal malrotation is the upper gastrointestinal series. However, in patients with acute abdomen associated with this pathology where is suspected intestinal ischemia and hemodynamic instability, it is essential that an emergency laparotomy be performed. Conclusions The diagnosis of intestinal malrotation is difficult, since many patients are asymptomatic in adulthood or present with variable GI symptoms. Therefore, it is imperative to have a high index of suspicion in patients with compatible clinical characteristics in order to perform the best therapy in time and manner.
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Ferreira MS, Simões J, Folgado A, Carlos S, Carvalho N, Santos F, Costa PM. Recurrent midgut volvulus in an adult patient - The case for pexy? A case report and review of the literature. Int J Surg Case Rep 2019; 66:91-95. [PMID: 31821981 PMCID: PMC6906706 DOI: 10.1016/j.ijscr.2019.11.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 12/25/2022] Open
Abstract
Intestinal malrotation and midgut volvulus in adulthood are rare events. Reports of recurrence among adults are very scarce. The rate of recurrence and optimal surgical management are yet to be determined. Bowel fixation procedures may be considered in Ladd procedures for adult midgut volvulus in order to reduce recurrence.
Introduction Intestinal malrotation is a rare condition, with an incidence estimated between 0,2 to 1%. Most cases are diagnosed and treated during childhood. Adult presentations are rare and most adults present with chronic nonspecific complaints. Midgut volvulus is the most feared complication of intestinal malrotation, far more common among the pediatric than the adult population. Presentation in adulthood with a midgut volvulus accounts for a minority of these patients (15%). The Ladd procedure is the standard surgical management of midgut volvulus and intestinal malrotation. Most evidence on the outcomes of the Ladd procedure originates from studies on pediatric population and the recurrence among children who have had a Ladd procedure is low (2–7%). Presentation of case We report an exceedingly rare case of a patient who presented in adulthood with a midgut volvulus and less than two years after undergoing Ladd procedure presented with a recurrence of the midgut volvulus. The recurrent midgut volvulus was successfully treated by a fixation procedure (cecopexy and duodenopexy). Conclusion Reports of midgut volvulus in adult patients are scarce and reports of recurrence even scarcer hence the rate of recurrence among adult patients has yet to be determined. The recurrence rate in some of the available adult series is much higher than the rate reported among children. Should the rate of recurrence among adult patients prove higher, it poses the question of whether the Ladd procedure should be modified to include bowel fixation when performed in adults.
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Affiliation(s)
- Margarida S Ferreira
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal; Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal.
| | - Joana Simões
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal
| | - António Folgado
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal; Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Sandra Carlos
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal
| | - Nuno Carvalho
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal; Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Filipa Santos
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal
| | - Paulo Matos Costa
- Department of General Surgery - Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal; Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
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Midgut malrotation complicated by small bowel obstruction in an 80-year-old woman: A case report. Int J Surg Case Rep 2019; 63:89-93. [PMID: 31574456 PMCID: PMC6796602 DOI: 10.1016/j.ijscr.2019.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/23/2019] [Accepted: 09/08/2019] [Indexed: 12/19/2022] Open
Abstract
Intestinal malrotation results from anomalies in embryological midgut rotation. Malrotation usually presents early in life, with rare cases reported in adulthood. Ladd procedure remains the mainstay of definitive treatment. Radiologic findings have a role in early detection and correction of malrotation.
Introduction Midgut malrotation results from abnormalities in the 270-degree counterclockwise rotation of the midgut around the axis of the superior mesenteric artery during embryological development, and classically presents early in life with symptoms of intestinal obstruction. Nevertheless, adult cases have occasionally been reported. Presentation of case An 80-year-old female with no surgical history was brought to our emergency department for acutely altered mental status. On exam, her abdomen was distended and diffusely tender to palpation. Computed tomography (CT) scan of the abdomen and pelvis showed a dilated loop of jejunum with evidence of mesenteric twist concerning for closed-loop small bowel obstruction. The patient was taken for exploratory laparotomy and was found to have Ladd bands and other findings suggestive of intestinal malrotation. A Ladd procedure was performed and the patient remained under observation. She experienced intermittent abdominal distension and bilious nasogastric tube output, but subsequent CT scans revealed no evidence of obstruction. She was discharged following clinical improvement and ability to tolerate a diet. Discussion Malrotation of the small bowel exists on a spectrum depending on the embryologic stage during which anomalous rotation occurs. Classic findings on CT imaging (including abnormal mesenteric vasculature, right-sided duodenojejunal junction, whirlpool signs, and left-sided ascending colon) can provide clues to the existence of malrotation. Conclusion Although malrotation is rare in adults, clinical and radiologic findings play an important role in the correct diagnosis of adult malrotation for appropriate and timely intervention.
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Butterworth WA, Butterworth JW. An adult presentation of midgut volvulus secondary to intestinal malrotation: A case report and literature review. Int J Surg Case Rep 2018; 50:46-49. [PMID: 30077833 PMCID: PMC6083817 DOI: 10.1016/j.ijscr.2018.07.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/03/2018] [Accepted: 07/08/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Midgut volvulus secondary to intestinal malrotation is a rare cause of an acute abdomen in adults, with 92 confirmed cases in the literature. Incidence of malrotation is estimated 1 in 6000 live births. 64-80% of malrotation cases present in the first month of life and 90% within the first year. Adult presentation is very rare accounting for only 0.2-0.5% of cases, of which only 15% present with midgut volvulus. PRESENTATION OF CASE We report a rare case of a 20 year old male with spontaneous midgut volvulus secondary to congenital malrotation of the bowel. Additionally we performed a literature review and analysis of the 92 cases of adult presentations of midgut volvulus secondary to malrotation. DISCUSSION Of the 92 cases, average patient age was 40 years old and a 1.7:1 male:female ratio. Diagnosis of midgut volvulus was predominantly made via CT (67%) but also by ultrasound (15%) and theatre (18%). Midgut volvulus is associated with a high risk of ischaemia and necrosis of bowel supplied by the SMA (35). 19% of cases reported required a bowel resection. The case discussed in this report required a 130 cm bowel resection which is similar to the mean bowel resection length in the literature of 121 cm. Mean associated mortality rate is 5%. CONCLUSION This case reinforces the importance of maintaining a high index of suspicion and closely monitoring patients presenting with non-specific abdominal pain, to allow early recognition and management of rare causes of the deteriorating surgical patient.
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Affiliation(s)
- William A Butterworth
- Princess Royal University Hospital, Farnborough Common, Orpington, Kent, England BR6 8ND, United Kingdom.
| | - James W Butterworth
- Imperial College London, Kensington, London, England SW7 2AZ, United Kingdom.
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Detecting Intestinal Malrotation on Hepatobiliary Scintigraphy: Making a Case for a Better Standardized Reporting Template. Clin Nucl Med 2018; 43:289-293. [PMID: 29401148 DOI: 10.1097/rlu.0000000000001983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intestinal malrotation displays classic pattern of the small bowel activity on hepatobiliary scintigraphy that could lead to the diagnosis, but only if an interpreting physician looks for it. Presented are 2 cases, one demonstrates diagnostic findings during the first 60-minute phase, whereas the other reveals the diagnosis only on the later sincalide stimulation phase. The currently recommended structured reporting for hepatobiliary scintigraphy does not include examination of bowel activity pattern, which could result in a missed diagnosis. Including interrogation of the small bowel pattern into the structured reporting checklist would ensure consistent detection of this rare but most consequential diagnosis.
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Nguyen D, Sessions W, Deitrick J, Olanrewaju A, Meller J. Nonbilious Vomiting in a 4-Week-Old Male: A Case Report and Review of the Literature. Glob Pediatr Health 2018; 5:2333794X17751010. [PMID: 29344560 PMCID: PMC5764131 DOI: 10.1177/2333794x17751010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 11/17/2017] [Indexed: 11/16/2022] Open
Affiliation(s)
- Daniel Nguyen
- Texas Tech Health Sciences Center, Amarillo, TX, USA
| | | | - Jena Deitrick
- Texas Tech Health Sciences Center, Amarillo, TX, USA
| | | | - Janet Meller
- Texas Tech Health Sciences Center, Amarillo, TX, USA
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